Psychiatrists should investigate their patients less

Psychiatrists often order investigations such as blood tests, neuroimaging and electroencephalograms for their patients. Rationales include ruling out 'organic' causes of psychiatric presentations, providing baseline parameters before starting psychotropic medications, and screening for general cardiometabolic health. Hospital protocols often recommend an extensive panel of blood tests on admission to a psychiatric ward. In this Against the Stream article, we argue that many of these investigations are at best useless and at worst harmful: the yield of positive findings that change clinical management is extremely low; special investigations are a poor substitute for a targeted history and examination; and incidental findings may cause anxiety and further unwarranted investigation. Cognitive and cultural reasons why over-investigation continues are discussed. We conclude by encouraging a more targeted approach guided by a thorough bedside clinical assessment

Transport in non-ideal, multi-species plasmas

Charged particle transport plays a critical role in the evolution of high energy-density plasmas. As high-fidelity plasma models continue to incorporate new micro-physics, understanding multi-species plasma transport becomes increasingly important. We briefly outline theoretical challenges of going beyond single-component systems and binary mixtures as well as emphasize the roles experiment, simulation, theory, and modeling can play in advancing this field. The 2020 Division of Plasma Physics mini-conference on transport in Transport in Non-Ideal, Multi-Species Plasmas was organized to bring together a broad community focused on modeling plasmas with many species. This special topics issue of Physics of Plasmas touches on aspects of ion transport presented at that mini-conference. This special topics issue will provide some context for future growth in this field

Chunchucmil’s Urban Population

The previous chapter established that nearly all of what we mapped at Chunchucmil was occupied at the end of the Early Classic period. This allows us to combine mapping and excavation to discuss the structure of the city at this critical time. As we explain below, settlement in and around Chunchucmil was not homogeneous. We lump this settlement into five zones each with different characteristics: (1) site center, (2) residential core, (3) residential periphery, (4) settlement fingers, and (5) hinterland. This chapter presents the characteristics (size, settlement density, kinds of occupation) of these zones and then supplies a population estimate

AICPA\u27s top technologies 2004

https://egrove.olemiss.edu/aicpa_guides/1588/thumbnail.jp

Meningococcal disease in children in Merseyside, England:a 31 year descriptive study

Meningococcal disease (MCD) is the leading infectious cause of death in early childhood in the United Kingdom, making it a public health priority. MCD most commonly presents as meningococcal meningitis (MM), septicaemia (MS), or as a combination of the two syndromes (MM/MS). We describe the changing epidemiology and clinical presentation of MCD, and explore associations with socioeconomic status and other risk factors. A hospital-based study of children admitted to a tertiary children's centre, Alder Hey Children's Foundation Trust, with MCD, was undertaken between 1977 to 2007 (n = 1157). Demographics, clinical presentations, microbiological confirmation and measures of deprivation were described. The majority of cases occurred in the 1-4 year age group and there was a dramatic fall in serogroup C cases observed with the introduction of the meningococcal C conjugate (MCC) vaccine. The proportion of MS cases increased over the study period, from 11% in the first quarter to 35% in the final quarter. Presentation with MS (compared to MM) and serogroup C disease (compared to serogroup B) were demonstrated to be independent risk factors for mortality, with odds ratios of 3.5 (95% CI 1.18 to 10.08) and 2.18 (95% CI 1.26 to 3.80) respectively. Cases admitted to Alder Hey were from a relatively more deprived population (mean Townsend score 1.25, 95% CI 1.09 to 1.41) than the Merseyside reference population. Our findings represent one of the largest single-centre studies of MCD. The presentation of MS is confirmed to be a risk factor of mortality from MCD. Our study supports the association between social deprivation and MCD

Wilms’ tumour antigen 1 Immunity via DNA fusion gene vaccination in haematological malignancies by intramuscular injection followed by intramuscular electroporation: a Phase II non-randomised clinical trial (WIN)

Background: In the UK almost 7000 people are diagnosed with leukaemia each year, but despite continuing advances in diagnosis and treatment with new drugs, such as the tyrosine kinase inhibitors, the majority of these patients will eventually die from their disease. Until quite recently, the only treatment to offer the possibility of long-term disease-free survival was allogeneic stem cell transplantation. However, this carries a substantial risk of mortality and is available to only a minority of patients.Objectives: The aim of the study was to test the hypothesis that molecular and clinical responses, induced by T lymphocytes (T cells), can be predicted by increases in the number of CD8+ (cluster of differentiation 8-positive) T cells specific for the vaccine-encoded T-cell epitopes. This project also aimed to build on the established programme of deoxyribonucleic acid (DNA) fusion-gene vaccination delivered by intramuscular injection, exploiting a unique experience with electroporation, to induce durable immune responses with the aim of controlling disease by precision attack of the tumour by CD8+ T cells.Method: A non-randomised, open-label, single-dose-level Phase II clinical trial in two patient groups [chronic myeloid leukaemia (CML) and acute myeloid leukaemia (AML)] on stable doses of imatinib. Human leucocyte antigen A2-positive (HLA A2+) patients were vaccinated with two DNA vaccines: (1) p.DOM–WT1-37 (epitope sequence: VLDFAPPGA); and (2) p.DOM–WT1-126 (epitope sequence: RMFPNAPYL). The HLA A2-negative patients formed an unvaccinated control group. The sample size for the HLA A2+ group was originally determined following Simon’s optimal Phase II trial design (Simon R. Optimal two-stage designs for phase II clinical trials. Control Clin Trials 1989;10:1–10). This was changed to A’Hern’s single-stage design during the course of the trial (A’Hern RP. Sample size tables for single-stage phase II designs. Stat Med 2001;20:859–66), which was endorsed by the trial’s independent oversight committees.Results: The study included 12 patients with CML who were vaccinated and nine patients with CML who were unvaccinated as the control group. Both the vaccines and the electroporation were safe, with no new or unexpected toxicities. The evaluation adverse events of special interest (heart, bone marrow, renal) did not reveal safety concerns. Two BCR–ABL (breakpoint cluster region–Abelson murine leukaemia viral oncogene homolog 1) responses were observed, both of which were defined as a major response, with one in each group. Two Wilms’ tumour antigen 1 (WT1) molecular responses were observed in the vaccinated group and one was observed in the control group. At an immunological level, the vaccine performed as expected.Conclusions: The study met its primary decision-making target with one major molecular response in BCR–ABL transcript levels. Overall, the data showed, in this clinical setting, the immunogenicity and safety of the vaccine.Limitations: The study did not complete recruitment and there were multiple hurdles that contributed to this failure. This is disappointing given the robust induction immune responses against WT1 T-cell responses in 7 out of 10 evaluable patients.Future work: Evaluation of the p.DOM–WT1 vaccines in AML remains attractive clinically, but it is unlikely to be feasible at this time. Combination of the DNA vaccine approach with strategies to expand T-cell responses with immunomodulatory antibodies is in development.Funding details: This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership, and Bloodwise

Evaluation of Transmitral Pressure Gradients in the Intraoperative Echocardiographic Diagnosis of Mitral Stenosis after Mitral Valve Repair

OBJECTIVE: Acute mitral stenosis (MS) following mitral valve (MV) repair is a rare but severe complication. We hypothesize that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair. METHODS: The medical records of 552 consecutive patients undergoing MV repair at a single institution were reviewed. Post-cardiopulmonary bypass peak and mean transmitral pressure gradients (TMPG), and pressure half time (PHT) were obtained from intraoperative transesophageal echocardiographic (TEE) examinations in each patient. RESULTS: Nine patients (9/552 = 1.6%) received a reoperation for primary MS, prior to hospital discharge. Interestingly, all of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not: 10.7±4.8 mmHg vs 2.9±1.6 mmHg; p<0.0001 and 22.9±7.9 mmHg vs 7.6±3.7 mmHg; p<0.0001, respectively. However, PHT varied considerably (87±37 ms; range: 20-439 ms) within the entire population, and only weakly predicted the requirement for reoperation (113±56 vs. 87±37 ms, p = 0.034). Receiver operating characteristic curves showed strong discriminating ability for mean gradients (AUC = 0.993) and peak gradients (area under the curve, AUC = 0.996), but poor performance for PHT (AUC = 0.640). A value of ≥7 mmHg for mean, and ≥17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not. CONCLUSIONS: Intraoperative TEE diagnosis of a peak TMPG ≥17 mmHg or mean TMPG ≥7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair

Home Ranges and Habitat Use of Brown Pelicans (\u3ci\u3ePelecanus occidentalis\u3c/i\u3e) in the Northern Gulf of Mexico

Little is known about movements and habitat use of Brown Pelicans (Pelecanus occidentalis) in the northern Gulf of Mexico. We attached satellite transmitters to 18 adult Brown Pelicans (nine males, nine females) that were captured on Grand Isle along the Louisiana coast during 31 August-2 September 2010. Their movements and habitat use were tracked between September 2010 and March 2012. Nine of the Brown Pelicans remained proximate to the Louisiana coast; four ranged along the coasts of Alabama, Mississippi, and Louisiana; three moved from Louisiana to Texas; and two migrated across the Gulf of Mexico to the Yucatan Peninsula. Annual 99% home range estimates varied widely ( = 10,611 km2, SE = 2,370), and males had larger ranges ( = 15,088 km2, SE = 2,219) than females ( = 6,133 km2, SE = 1,764). Habitats used by Brown Pelicans were primarily open water, estuarine emergent wetland, grassland, unconsolidated shore, and deep water habitat types

Home Ranges and Habitat Use of Brown Pelicans (\u3ci\u3ePelecanus occidentalis\u3c/i\u3e) in the Northern Gulf of Mexico

Little is known about movements and habitat use of Brown Pelicans (Pelecanus occidentalis) in the northern Gulf of Mexico. We attached satellite transmitters to 18 adult Brown Pelicans (nine males, nine females) that were captured on Grand Isle along the Louisiana coast during 31 August-2 September 2010. Their movements and habitat use were tracked between September 2010 and March 2012. Nine of the Brown Pelicans remained proximate to the Louisiana coast; four ranged along the coasts of Alabama, Mississippi, and Louisiana; three moved from Louisiana to Texas; and two migrated across the Gulf of Mexico to the Yucatan Peninsula. Annual 99% home range estimates varied widely ( = 10,611 km2, SE = 2,370), and males had larger ranges ( = 15,088 km2, SE = 2,219) than females ( = 6,133 km2, SE = 1,764). Habitats used by Brown Pelicans were primarily open water, estuarine emergent wetland, grassland, unconsolidated shore, and deep water habitat types